Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephoner (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.71',16' <br /> THIS' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 10-3-7- <br /> (Complete <br /> 0,3.7(Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local,Health District- for a permit to construe <br /> and/or install the work herein described. This application is-made. in compliance with San Joaquin <br /> County Ordinance No, 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION : 5q30 RL CENSUS TRACT :, <br /> Owner's Name �, oig Phone <br /> Address - �,, l.� CSS �.. Cir <br /> i ,I <br /> Contractor's Name �, �, (+ License 06 Phone <br /> TYPE OF WORK (Check) : NEW WELL; ,DEEPEN.;/_.�. RECONDITION -%./�DESTRUCTION /� <br /> i PUMP INST ATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <br /> -- <br /> DISTANCE TO}NEAREST: SEPTIC TANK SEWER LINES PIT .PRIVY' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER s . <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC, WELL <br /> INTENDED USE. TYPE OF WELL CONSTRUCTION. SPECIFICATIONSt <br /> Industrial Cable Tool. Dia. of Well Excavation. <br /> ✓ Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public -Driven Gauge of Casing <br /> Irrigation ravel Pack Depth of Grout Seal <br /> Cathodic Protection L Rotary Type of Grout <br /> Disposal Other Other. Information ' <br /> Geophysical -- Sur_face Seal Installed By: <br /> -PINSTALLATION: Contractor <br /> Type of Pump H.P.- f <br /> [ PUMP REPLACEMENT:- / / State Work Done..- 7' <br /> PUMP .REPAIR: " <br /> • , � / / State Work Done n <br /> _ Well Diameter Approximate Depth <br /> DESTRUCTION OF WEI'L': �, t <br /> ' Describe Material and Procedure_ <br /> I hereby agree to�comp]y with all laws and regulations of the-San Joaquin Local Health District '- <br /> ? and the State of California pertaining to or regulating well construction. Within- FIFTEEN DAYS <br /> after completion of my work� on a new well, I,willr-furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting. the. well in use.... The above <br /> ` information is true to the best of my knowledge and•ybelief. I WILL CALL FOR A GROUT INSPECTION:'°` - <br /> PRIOR TO GR, ING;AND A°°FINAL INSPECTION. e� <br /> SIGNED TITLE <br /> (DRAW <br /> ..µ <br /> (DRAW PLOT PLAN ON. REVERSE SIDE) <br /> F FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED"BY"�'�'""'�"' --" �� �. � ' _ DATE 3-77 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION " <br /> INSPECTION BY s', K DATE INSPECTION BY DATE o , <br /> A • <br /> 1426" _ 6177 2Mk 7 <br /> � <br />